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...Northern Territory (Department Health and Community Services 2004:24). Aboriginal deaths from respiratory diseases are six times higher than non-Aboriginal deaths; from diabetes, eight times higher; from renal failure, eleven times higher; from homicide, six times higher; and from child infection, fifteen times higher (Territory Health Services 1996:21). Aboriginal Territorians have both burden of disease (Zhao et al. 2004) and a hospitalisation rate (Department of Health and Community Services 2004:31) that is 2.5 times higher than that of non-Aboriginal Territorians. As a result, over half of the Northern Territory health budget is spent on Aboriginal people, who make up approximately one third of the population (Department of Health and Community Services 2004:35). What these statistics do not reflect is that Aboriginal people consider themselves vulnerable to a wide variety of diseases, some of which are not considered to be the domain of biomedicine, such as illness caused by sorcery.
In remote Aboriginal communities in Australia two healing traditions--Aboriginal and Western/biomedical--are often considered to exist. Researchers writing from the different perspectives of health care practitioners (Devanesen 1985; Gray 1979; Maher 1999), anthropologists (Mobbs 1991; Reid 1983), and political advocacy (Nathan and Leichleitner 1983; Saggers and Gray 1991) support this distinction. Despite the varying approaches employed by these authors to understand and propose methods of combating poor Aboriginal health, which range from encouraging greater rates of Aboriginal treatment at government clinics to arguing for independent Aboriginal health services, there is a general agreement that fundamental differences between Aboriginal and biomedical approaches to health exist. Each tradition is considered to have its own history, ethos, aetiology, and treatment options. In many instances both Aboriginal healing beliefs and biomedicine are essentialised and reified, with much of the variation within both of these approaches being forgotten. For instance, biomedicine at Harvard Medical School is different from biomedicine in a remote area clinic in Central Australia. Likewise, there is a wide range of Aboriginal ideas regarding health and well being across the continent, making it difficult if not impossible to accurately simplify this complexity.
Nevertheless, many researchers attempt to typify the essential characteristics of both biomedicine and Aboriginal healing beliefs. The Aboriginal medical system is often cast as holistic, personal and social (Morgan et al. 1997:598; Nathan and Leichleitner 1983:91). It 'seeks to provide a meaningful explanation for illness and to respond to the personal, family and community issues surrounding illness' (Devanesen 1985:33). The link between health and social relations is often stressed (Devanesen 1985; Mobbs 1991; Morgan et al. 1997; Nathan and Leichleitner 1983; Reid 1983) and illness is characterised by 'social and spiritual dysfunction' (Maher 1999:230). In contrast, biomedicine is cast as 'particularistic, biophysical and mechanistic' (Nathan and Leichleitner 1983:91). Biomedicine is considered to view the body as a machine and illness as a malfunction of this machine (Fabrega and Silver 1973:218-223; Kirmayer 1988:57-60; Kleinman 1980:108). It is also common to portray the biomedical approach as casting disease as the result of physical and environmental factors, not social ones (Devanesen 1985: 33; Morgan et al. 1997:589; Nathan and Leichleither 1983:91).
Aboriginal and biomedical health systems are believed to be 'vastly different in philosophy and practice' (Nathan and Leichleitner 1983:72), and are compared in terms of a 'stark contrast' (Mobbs 1991:302) and a 'cultural gap' (Eastwell 1973:1012). 'Competing' (Nathan and Leichleitner 1983:70), 'poor compatibility' (Maher 1999:234) and 'clash' (Sutton 2005:1) are common ways of characterising the relationship between these two approaches. This cultural disparity is often considered to create barriers to effective clinical treatment. On one hand, the social environment of clinics is said to discourage some Aboriginal people from obtaining treatment (Mobbs 1991:314; Morgan et al. 1997:599), and indeed Aboriginal people can feel intimidated and uncomfortable in the biomedical setting of hospitals and clinics. On the other, Aboriginal beliefs in supernatural causes of disease are said to discourage Aboriginal people from presenting at the clinic for treatment for some illnesses. Tina, (1) the nurse in charge of the clinic through much of my fieldwork said, 'Sometimes [Aboriginal people] think that they are suffering from sorcery so they don't come in until their condition gets really bad. Then we have to evacuate them. If they would just come in earlier it would save us money and keep them alive longer.' As a result, researchers frequently discuss biomedicine's poor social and cultural fit in traditional settings (Mobbs 1991 ; Public Accounts Committee 1996; Saggers and Gray 1991).
For decades, the assumed disparity between biomedical and Aboriginal health systems and its effect on health outcomes has been treated as a reality, motivating the introduction of programs aimed at integrating these perspectives. As early as the late 1970s, some health care professionals in the Northern Territory introduced the concept of 'two way' medicine. Ideally under a 'two way' approach, illness management continues to occur in the clinic, but patients would have the choice of consulting nurses, Aboriginal Health Workers, or Aboriginal healers and being prescribed pharmaceuticals or bush medicines. Devanesen (1985:36) claims that this approach bridges 'the cultural chasm separating the traditional and western world views.' 'Two way' medicine has come under criticism for favouring biomedicine and not adequately incorporating Aboriginal views (Burnett 1996:5; Humphrey, Dixon, and Marrawal 1998:100; Nathan and Leichleitner 1983:68; Saggers and Gray 1991:150). By the late 1990s, 'two way' medicine was largely deemed to be impossible to implement despite its intentions. In 1997, a nurse who had worked for fifteen years in Aboriginal community clinics remarked that 'two way' medicine had 'never worked' and expressed relief that the Northern Territory seemed to be moving away from its philosophy.
From 1996 to 2000, I spent twenty-six months conducting ethnographic research in a remote Warlpiri community in the Northern Territory. It has a population of approximately seven hundred inhabitants and like other remote Aboriginal communities in the Northern Territory, there is low labour force participation, many people are dependent upon government benefits, most homes are overcrowded and in disrepair, and nutritional health is poor. The first nurse arrived in the community five years after it was established--over fifty years ago--and found that nutrition was inadequate, scurvy was rampant, hookworm was spreading rapidly, 38% of the population had tuberculosis, and 32% had trachoma (Kettle 1991:73). It was another three years before a nurse was permanently assigned to the community but staffing problems continued to plague the clinic, which, during my fieldwork, had only two permanent positions for nurses. Although some of the health concerns have changed since the community was established, the Aboriginal residents continue to suffer from high rates of illness. To combat disease, residents have access to a wide range of healing options including medical staff, local healers, pharmaceuticals, and bush medicines. I was curious to know how and when each alternative was utilised.
Throughout the many interviews that I conducted, people echoed the views of much of the literature relating to Aboriginal health: there are two discreet systems. As I became more familiar with the community and its residents, I began recording illness episodes. Like others who had researched Aboriginal health (Beck 1985:84; Cawte 1974:43; Cutter 1976:38; Gray 1979:172; Skov 1994:20; Tonkinson 1982:229), I noticed that individuals used a variety of healing aids and technologies from both traditions. What struck me as important was not that Warlpiri people were able to use both systems but rather how they did so. Warlpiri people spoke of two different traditions, but in case after case, similar issues and concerns were at stake. Consequently, I believe that the assumption that biomedicine and Aboriginal healing beliefs are invariably conflicting and incompatible should be re-evaluated. I will demonstrate that there is a great degree of complexity in Warlpiri health behaviour that tends to be overlooked if simplistic and dichotomous models of health care systems are employed. First, though, it necessary to begin by reviewing how Warlpiri people in the community discuss the difference between Warlpiri and biomedical health traditions and their stated motivations for choosing a treatment from either of these medical systems. I will then examine two illness episodes as a means of contrasting the statements of individuals with the actions of individuals. Finally, I will return to the issue of how Aboriginal people can use what appear to be two very incompatible systems in a very complementary way.
YAPA-KURLANGU AND KARDIYA-KURLANGU
The division between biomedical and Aboriginal ideas about illness and healing is one that Aboriginal people themselves widely recognise (Maher 1999:234; Nathan and Leichleitner 1983:133; Reid 1983:134). Warlpiri people, from teenagers to the elderly, explicitly distinguish between two domains: yapa-kurlangu (belonging to Aboriginal people) and kardiya-kurlangu (belonging to white people). Individuals are able to class illnesses, and their causes, as belonging to either one of these groups. However, this division is not comprehensive and often relies upon a much more fundamental distinction: that between physical and spiritual illnesses. (2) Spiritual illness is caused by the effect of a person's soul moving from its resting place in the solar plexus; having a foreign object, usually a sharpened piece of bone called a yarda, magically implanted in it; or being removed--on the body. Most spiritual illness is attributed to the intervention of ghosts or sorcerers, although fright or the breaking of customary law could also precipitate a spiritual illness. All spiritual illnesses are referred to as yapa-kurlangu. Audrey, 28 years old, explained, 'Sometimes we get sick from magic. Kardiya don't get sick this way; only yapa. It is yapa-kurlangu.' Warlpiri people are aware that biomedicine fails to recognise spiritual illness. Liddy, 42 years old, said, 'Those doctors, they don't understand Aboriginal sickness. They do x-rays but they still can't see that bone...
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